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Tuberculosis detection: Process

Tuberculosis detection: Process

Tuberculosis detection: Training

Tuberculosis detection: Training

Tackling Tuberculosis in Megacities

In Tanzania, tuberculosis (TB) is the third major cause of disease and death after malaria and HIV/AIDS, and the country is one of the 22 high-TB burden countries in the world. Apart from other factors such as poverty and the HIV epidemic, the lack of a fast, efficient and simple TB diagnostic method is the main reason for the fast spread of tuberculosis.

APOPO started its second-line TB screening program in mid-2008 after the successful completion of the proof of principle study. Second-line screening means sputum samples are screened primarily at the diagnostic facilities of TB clinics and then screened for the second time by trained rats. Sputum samples that were negative at the TB clinics diagnostic laboratory but found positive by the trained rats are confirmed at APOPO’s diagnostic laboratory. The confirmed results are sent back to the respective TB clinics for patient tracking, treatment and follow up.

Dar es Salaam contributes more than 20% of the Tanzanian national TB burden and APOPO utilizes its innovative detection technology for the containment of the deadly disease in this emerging African megacity. The second-line screening program started with four TB clinics and rapidly expanded to currently serve fourteen. A TB detection rat can screen 40 sputum samples in just seven minutes, which is equal to what a skilled lab technician would handle in a full day’s work. Because the rats can screen hundreds of samples in a single day, APOPO will seek for further expansion with the goal of covering all 62 TB diagnostic centers in Dar es Salaam.

APOPO’s rats detected thousands of TB patients who were initially diagnosed negative in the TB clinics. As every untreated patient can infect 10 to 15 other people per year, APOPO’s intervention had a major multiplication effect on preventing TB transmissions. This operation also serves as a quality control tool that identifies the diagnostic centers with the most missed cases. APOPO collaborates with the National Tuberculosis and Leprosy Program (NTLP) and its Central Tuberculosis Reference Laboratory (CTRL) to institute stringent quality control measures and to provide refresher training for laboratory personnel.

To track and treat patients who have been sent home earlier based on a negative microscopic test is a major challenge. To tackle this, APOPO recently established a partnership with a Tanzanian NGO called Mapambano ya Kifua Kikuu na Ukimwi Tanzania (MKUTA), which is composed of former TB patients. MKUTA volunteers are talking and convincing each and every TB suspect so as to provide a reliable telephone number and physical address that would make tracking at a later stage easy. A pilot implementation of this exercise produced promising results which will lead to a long term partnership agreement with MKUTA.

APOPO aims to curb the spread of TB in Dar es Salaam, and hopes that this project can demonstrate the viability of the implementation in other megacities.

Rats for TB control in Maputo city

In 2011, Mozambique reported an estimated TB prevalence of 548 cases per 100,000 inhabitants, versus a global prevalence of 170 cases per 100,000 inhabitants. Like in other Sub-Saharan African countries, co-infection with HIV is an important factor; in Mozambique more than 60% of the tested TB patients are infected with the HIV virus.

The APOPO TB project in the city of Maputo, Mozambique, intends to replicate the activities and successful results obtained by TB detection rats in Tanzania. In implementing this project, APOPO expects to contribute to the Mozambican National TB Control Program by effectively increasing the number of identified TB patients in a short period. Also, project implementation aims to create a local capacity of TB detection rats and trainers to support a long term impact on reducing the TB problem in Mozambique. For this purpose, APOPO is partnering with the Mozambican Ministry of Health and the Eduardo Mondlane University through a series of institutions, namely the National Institute of Health, the National TB Control Program, Medicine and Veterinary Schools, and the Maputo City Health Directorate.

In starting the project, APOPO has built and equipped a TB detection rat facility at the Vet School of the Eduardo Mondlane University. A total of eight health centers in the city of Maputo are collaborating with the project, providing sputum samples of TB suspected patients. APOPO rats evaluate all suspected samples, indicating additional TB cases initially missed by microscopy tests performed at health centers. Those samples indicated by the rats are confirmed by LED microscopy, a more sensitive laboratory technique. The additional positive samples detected by the rats are communicated back to the health centers, thus allowing them to trace the patients back and start them on TB treatment.

At the end of this first phase, APOPO expects to have its detection rat technology well established in the city of Maputo and improving significantly the TB detection rates at participant health centers.

A second phase will then start where APOPO will seek to increase the number of collaborating health centers, both in the city of Maputo and the rest of the country. A number of clinical and epidemiological studies are being planned to further strengthen the APOPO detection rat technology.

As a summary, thousands of TB cases which otherwise would be missed by conventional microscopy will be diagnosed by APOPO'’s innovative technology and will be treated effectively by the National TB Program.

Research and Development for TB eradication

APOPO’s Tuberculosis (TB) Research Laboratory located in Morogoro, Tanzania, was established in 2005. This distinctive laboratory, the first ever to evaluate rats as a diagnostic tool in human health, has developed a solid empirical base and has received worldwide recognition for its accomplishments. International agencies, such as the World Bank, the UBS Optimus Foundation and the National Institute of Health are among the supporters of the research. Importantly, as the technical evidence of APOPO’s tuberculosis screening method using rats grows, so does APOPO’s operational impact.

The TB Laboratory has three main functions: first, to conduct empirical evaluations on the rats in collaboration with our scientific partners; second, to use these findings to improve internal operational capabilities; and third, to train TB detection rats and provide training for local and international staff, students and researchers.

The Laboratory houses a fully functional sample processing facility with a safety cabinet, autoclave, centrifuge, multiple infrared microscopes, and safety equipment. The Laboratory also houses four rat-training rooms: one for the pre-training stages, one for research activities, and two that are shared between research and operational activities. The laboratory currently processes around 800 samples per week, collected from the TB clinics in Dar es Salaam for screening by rats.

The long-term mission of the TB Research Laboratory is to validate a cost-effective and high-impact detection rat platform that may be used by independent entities in several other high-TB burden countries. APOPO’s long-term strategy, should the outcomes be sufficiently good, aims to incorporate the rats into the international tuberculosis control strategy. The strategy involves four major components: 1) evaluation of the technology on a large scale, 2) development of the evidence base for the technology, 3) demonstration of the cost-effective and the social impact of the technology, and 4) capacity building.

The TB Laboratory has made strides toward meeting the first two components of the strategy, including the completion of a proof-of-principle study and a major evaluation that compared the rats to microscopy relative to culture with Polymerase Chain Reaction (PCR). To read more on the pilot study click here and to read more on the comparison to culture study click here. Please see our list of publications to find out even more.

APOPO has several research studies planned for completion in the next 3-5 years that will further improve the effectiveness and impact of our TB operations; one group of studies will appraise how the rats are used and for which populations they are suitable while a second group of studies will internally and externally evaluate cost-effectiveness and social impact.

An important test planned for the upcoming year is to evaluate the rats as a first-line screening tool. As first-line screeners, a small group of rats would evaluate a pool of untested sputum samples and rat-positive samples would be further confirmed by, for example, microscopy or Cepheid GeneXpert (i.e. automated PCR). As first-line screeners, the rats may be suitable for use in prisons, refugee camps, or neighborhoods underserved by the national health care program, to name a few potential beneficiaries.

APOPO’s staff, management, and the little HeroRATs are excited to explore the potential of this simple, yet life-changing concept.